Healthcare Provider Details

I. General information

NPI: 1841280526
Provider Name (Legal Business Name): LAUREN MARY JOHNSON ATC, LAT, ARRT (MRI)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 W THUNDERBIRD RD
GLENDALE AZ
85306-4622
US

IV. Provider business mailing address

13809 N 49TH AVE
GLENDALE AZ
85306-4922
US

V. Phone/Fax

Practice location:
  • Phone: 602-865-5594
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0415
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: